Healthcare Provider Details

I. General information

NPI: 1750086559
Provider Name (Legal Business Name): JEFFERSON ABRAHAM JOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

IV. Provider business mailing address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4102
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01100183A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: